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A lesion to learn: Stroke mimics
apollo medicine 13 (2016) 42–45
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
A lesion to learn: Stroke mimics§ Mahir Meman a,*, Pushpendra Nath Renjen b, Dinesh M. Chaudhari a a
Internal Medicine Resident, Institute of Neurosciences/Internal Medicine, Indraprastha Apollo Hospitals, New Delhi 110076, India b Sr. Consultant Neurologist & Academic Coordinator, Institute of Neurosciences, Indraprastha Apollo Hospitals, New Delhi 110076, India
article info
abstract
Article history:
Acute ischemic stroke with neurological deficit is a very debilitating condition, especially in
Received 16 February 2016
younger patients. IV thrombolysis is the only effective treatment available in most of the
Accepted 18 February 2016
centers across India. But delay in hospitalization and bleeding complications are major
Available online 26 March 2016
limitations. In addition to that, stroke mimics are another big problem. Correct identification of stroke mimics needs clinical expertise and imaging studies. Multiple studies indicate
Keywords: Acute ischemic stroke
safety of thrombolysis in stroke mimics. Here, we are reporting a case to highlight this issue. # 2016 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
Stroke mimics
reserved.
IV Thrombolysis
1.
Introduction
Acute ischemic stroke (AIS) with neurological deficit is a very debilitating condition, especially in younger patients. IV Thrombolysis is the only effective treatment available in most of the centers across India. But delay in hospitalization and bleeding complications are major limitations. In addition to that, stroke mimics are another big problem. The rate of false positive diagnosis of ischemic stroke labeled ‘‘stroke mimics’’ ranges from 1.3% to 25%.1–3 Here, we are reporting a case to highlight this issue.
2.
Case report
A 21-year-old right-handed female had history of sudden onset numbness and weakness of left side of body with §
slurring of speech and facial deviation on 14th December 2015 around 3.30 pm. She had a similar episode in the morning (14/ 12/15) at 10 am. NCCT head was normal (Fig. 1). She was thrombolyzed by IV tPA (0.9 mg/kg) within 2.5 h at an alternate center. Post-thrombolysis, she was improved but developed 2 episodes of seizure (GTCS) on the next day and was put on an antiepileptic. All routine investigations were normal. MRI showed patchy hyperintensities in right high parietal region involving cortical and subcortical white matter on T2, FLAIR, and DWI suggestive of acute infarct. She continued to have seizures. She presented to our institute on 18th December 2015 for further treatment. She denied any accompanied symptoms like headache, sweating, seizure, blurring of vision, and loss of consciousness at the time of episode. She was diagnosed as PCOD and is on OCPs since last 1 year for the same. There was no history of atherosclerotic risk factors, such as smoking, diabetes, hypertension, or hyperlipidemia. On admission, her
This is a case report from the Department of Neurology, Indraprastha Apollo Hospitals, New Delhi, India. * Corresponding author at: Department of Internal Medicine, Indraprastha Apollo Hospitals, New Delhi 110076, India. Tel.: +91 9811730547. E-mail address: [email protected] (M. Meman). http://dx.doi.org/10.1016/j.apme.2016.02.005 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.
[(Fig._1)TD$IG]
apollo medicine 13 (2016) 42–45
Fig. 1 – NCCT head.
43
44
apollo medicine 13 (2016) 42–45
[(Fig._2)TD$IG]
Fig. 2 – MRI brain.
blood pressure was 120/80 mm Hg. She had a regular heart rate of 80 min–1 and a respiratory rate of 16 breaths per minute. Neither pathological breath sounds nor heart murmurs were auscultated. Nervous system examination was normal. Routine investigations were within normal limits. Looking at the shape and unusual location of infarct, MR venogram with contrast was done, which showed bilateral subacute hemorrhagic infarcts in evolution, possibly cortical venous infarct. Leptomeningeal and dural enhancement were also seen (Figs. 2 and 3). Coagulation workup was also normal. She was treated with anticoagulants and antiepileptics and discharged on 26th December 2015. On follow-up, she is found to be doing well.
3.
Stroke mimics
There is no general agreement as to the definition of stroke mimics.2,3 Stroke mimics comprise patients having eventually a final diagnosis other than stroke. Common stroke mimics are epileptic seizures with postictal confusion, complicated migraine, brain tumors, encephalitis, metabolic encephalopathy, conversion disorders, and sometimes, cardiac failure. On clinical examination, a mimic was more likely if there was a known history of cognitive impairment, the patient lost consciousness or had a seizure at onset, the patient could still walk, there were no lateralizing symptoms, and the examination revealed confusion, signs in other nonvascular systems (e.g., chest crackles), and no neurological signs (P < 0.05 for all). A mimic was also more likely if the signs were inconsistent with the symptoms or did not conform to known vascular territory.2 Libman et al.4 found that female gender, abnormal visual fields, diastolic blood pressure >90 mm Hg, and atrial fibrillation increased the odds of stroke; and normal eye movements and an abnormal neurological examination increased the odds of a mimic. The stroke physician must balance the clinical principles of
primum non tardare and primum non nocere,5 the need for speed and need for accuracy.
4. CVT masquerading: an ischemic brain stroke Cerebral venous thrombosis (CVT), an infrequent but fascinating condition, is remarkable for its extreme diversity, which still makes it a diagnostic and therapeutic challenge. Headache, focal deficits, seizures, disorders of consciousness, and papilledema, which can present in isolation or in association, are the most frequent signs.6 The mode of onset is highly variable, anything from sudden to progressive over weeks, so that CVT can mimic a host of conditions, such as ischemic or hemorrhagic stroke, abscess, tumor, encephalitis, metabolic encephalopathy, and benign intracranial hypertension. A CT scan is usually the first investigation performed on an emergency basis. Although it can sometimes detect the spontaneously hyperdense thrombosed sinus, it usually shows nonspecific changes, such as hypodensities, hyperdensities, and contrast enhancement; in up to 30% of cases it is normal.6,7 At present, ‘‘gold standard’’ for the diagnosis of CVT is MR angiography or helical CT venography.
5.
IV Thrombolysis in stroke mimics
As stated above, AIS is a clinical diagnosis and IV thrombolysis for acute stroke is usually based on clinical assessment, blood tests, and CT findings.8 Thrombolysis of stroke mimics thereby may occur. However, studies indicates that IV thrombolysis does not adversely affect favorable outcomes of stroke mimics, and treatment benefit from tPA would not be counterbalanced by the potential for harm to patients presenting with conditions mimicking AIS (a common concern among emergency physicians for precluding tPA use).9,10 Multicenter
apollo medicine 13 (2016) 42–45
[(Fig._3)TD$IG]
45
avoidance of unnecessary thrombolytic therapy in stroke mimics. Like in this case, the patient presents with classical history of acute stroke with normal NCCT head, but age and h/ o OCPs are important features in the presented case. Correct identification of stroke mimics needs clinical expertise and imaging studies. Time-bound clinical as well as imaging assessment is needed to exclude stroke mimic and avoidance of IV thrombolysis in stroke mimics. At the same time, effective thrombolysis in AIS is a good modality to decrease morbidity and mortality. As discussed above, multiple studies indicate safety of thrombolysis in stroke mimics. These findings offer reassurance to stroke physicians not to preclude potential candidates for thrombolytic therapy based on the sole concern that their neurological symptoms may be attributed to stroke mimics.
Conflicts of interest The authors have none to declare.
references
Fig. 3 – MR venogram.
cohort study done by Zinkstok et al.11 concluded that among patients treated with IV thrombolysis, only a few had a final diagnosis other than stroke and complication rate in these stroke mimics was low.
6.
Discussion
The idea of reporting this case is only to highlight the importance of correct identification of stroke mimics and
1. Hemmen TM, Meyer BC, McClean TL, Lyden PD. Identification of nonischemic stroke mimics among 411 code strokes at the University of California, San Diego, Stroke Center. J Stroke Cerebrovasc Dis. 2008;17: 23–25. 2. Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. Distinguishing between stroke and mimic at the bedside: the Brain Attack Study. Stroke. 2006;37:769–775. 3. Ay H, Buonanno FS, Rordorf G, et al. Normal diffusionweighted MRI during stroke-like deficits. Neurology. 1999;52:1784–1792. 4. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. 1995;52:1119–1122. 5. Lyden PD. Extending the time window for thrombolytic therapy: primum non tardare. Lancet Neurol. 2009;8: 1074–1075. 6. Bousser MG, Ross Russell R. Cerebral Venous Thrombosis. vol. 1. London, UK: WB Saunders Co.; 1997: 175. 7. Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin. 1992;10:87–111. 8. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–1711. 9. Mouradian MS, Rodgers J, Kashmere J, et al. Can rtPA be administered to the wrong patient? Two patients with somatoform disorder. Can J Neurol Sci. 2004;31:99–101. 10. Brown DL, Barsan WG, Lisabeth LD, Gallery ME, Morgenstern LB. Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke. Ann Emerg Med. 2005;46:56–60. 11. Zinkstok SM, Engelter ST, Gensicke H, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013;44(April (4)):1080–1084.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
A lesion to learn: Stroke mimics§ Mahir Meman a,*, Pushpendra Nath Renjen b, Dinesh M. Chaudhari a a
Internal Medicine Resident, Institute of Neurosciences/Internal Medicine, Indraprastha Apollo Hospitals, New Delhi 110076, India b Sr. Consultant Neurologist & Academic Coordinator, Institute of Neurosciences, Indraprastha Apollo Hospitals, New Delhi 110076, India
article info
abstract
Article history:
Acute ischemic stroke with neurological deficit is a very debilitating condition, especially in
Received 16 February 2016
younger patients. IV thrombolysis is the only effective treatment available in most of the
Accepted 18 February 2016
centers across India. But delay in hospitalization and bleeding complications are major
Available online 26 March 2016
limitations. In addition to that, stroke mimics are another big problem. Correct identification of stroke mimics needs clinical expertise and imaging studies. Multiple studies indicate
Keywords: Acute ischemic stroke
safety of thrombolysis in stroke mimics. Here, we are reporting a case to highlight this issue. # 2016 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
Stroke mimics
reserved.
IV Thrombolysis
1.
Introduction
Acute ischemic stroke (AIS) with neurological deficit is a very debilitating condition, especially in younger patients. IV Thrombolysis is the only effective treatment available in most of the centers across India. But delay in hospitalization and bleeding complications are major limitations. In addition to that, stroke mimics are another big problem. The rate of false positive diagnosis of ischemic stroke labeled ‘‘stroke mimics’’ ranges from 1.3% to 25%.1–3 Here, we are reporting a case to highlight this issue.
2.
Case report
A 21-year-old right-handed female had history of sudden onset numbness and weakness of left side of body with §
slurring of speech and facial deviation on 14th December 2015 around 3.30 pm. She had a similar episode in the morning (14/ 12/15) at 10 am. NCCT head was normal (Fig. 1). She was thrombolyzed by IV tPA (0.9 mg/kg) within 2.5 h at an alternate center. Post-thrombolysis, she was improved but developed 2 episodes of seizure (GTCS) on the next day and was put on an antiepileptic. All routine investigations were normal. MRI showed patchy hyperintensities in right high parietal region involving cortical and subcortical white matter on T2, FLAIR, and DWI suggestive of acute infarct. She continued to have seizures. She presented to our institute on 18th December 2015 for further treatment. She denied any accompanied symptoms like headache, sweating, seizure, blurring of vision, and loss of consciousness at the time of episode. She was diagnosed as PCOD and is on OCPs since last 1 year for the same. There was no history of atherosclerotic risk factors, such as smoking, diabetes, hypertension, or hyperlipidemia. On admission, her
This is a case report from the Department of Neurology, Indraprastha Apollo Hospitals, New Delhi, India. * Corresponding author at: Department of Internal Medicine, Indraprastha Apollo Hospitals, New Delhi 110076, India. Tel.: +91 9811730547. E-mail address: [email protected] (M. Meman). http://dx.doi.org/10.1016/j.apme.2016.02.005 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.
[(Fig._1)TD$IG]
apollo medicine 13 (2016) 42–45
Fig. 1 – NCCT head.
43
44
apollo medicine 13 (2016) 42–45
[(Fig._2)TD$IG]
Fig. 2 – MRI brain.
blood pressure was 120/80 mm Hg. She had a regular heart rate of 80 min–1 and a respiratory rate of 16 breaths per minute. Neither pathological breath sounds nor heart murmurs were auscultated. Nervous system examination was normal. Routine investigations were within normal limits. Looking at the shape and unusual location of infarct, MR venogram with contrast was done, which showed bilateral subacute hemorrhagic infarcts in evolution, possibly cortical venous infarct. Leptomeningeal and dural enhancement were also seen (Figs. 2 and 3). Coagulation workup was also normal. She was treated with anticoagulants and antiepileptics and discharged on 26th December 2015. On follow-up, she is found to be doing well.
3.
Stroke mimics
There is no general agreement as to the definition of stroke mimics.2,3 Stroke mimics comprise patients having eventually a final diagnosis other than stroke. Common stroke mimics are epileptic seizures with postictal confusion, complicated migraine, brain tumors, encephalitis, metabolic encephalopathy, conversion disorders, and sometimes, cardiac failure. On clinical examination, a mimic was more likely if there was a known history of cognitive impairment, the patient lost consciousness or had a seizure at onset, the patient could still walk, there were no lateralizing symptoms, and the examination revealed confusion, signs in other nonvascular systems (e.g., chest crackles), and no neurological signs (P < 0.05 for all). A mimic was also more likely if the signs were inconsistent with the symptoms or did not conform to known vascular territory.2 Libman et al.4 found that female gender, abnormal visual fields, diastolic blood pressure >90 mm Hg, and atrial fibrillation increased the odds of stroke; and normal eye movements and an abnormal neurological examination increased the odds of a mimic. The stroke physician must balance the clinical principles of
primum non tardare and primum non nocere,5 the need for speed and need for accuracy.
4. CVT masquerading: an ischemic brain stroke Cerebral venous thrombosis (CVT), an infrequent but fascinating condition, is remarkable for its extreme diversity, which still makes it a diagnostic and therapeutic challenge. Headache, focal deficits, seizures, disorders of consciousness, and papilledema, which can present in isolation or in association, are the most frequent signs.6 The mode of onset is highly variable, anything from sudden to progressive over weeks, so that CVT can mimic a host of conditions, such as ischemic or hemorrhagic stroke, abscess, tumor, encephalitis, metabolic encephalopathy, and benign intracranial hypertension. A CT scan is usually the first investigation performed on an emergency basis. Although it can sometimes detect the spontaneously hyperdense thrombosed sinus, it usually shows nonspecific changes, such as hypodensities, hyperdensities, and contrast enhancement; in up to 30% of cases it is normal.6,7 At present, ‘‘gold standard’’ for the diagnosis of CVT is MR angiography or helical CT venography.
5.
IV Thrombolysis in stroke mimics
As stated above, AIS is a clinical diagnosis and IV thrombolysis for acute stroke is usually based on clinical assessment, blood tests, and CT findings.8 Thrombolysis of stroke mimics thereby may occur. However, studies indicates that IV thrombolysis does not adversely affect favorable outcomes of stroke mimics, and treatment benefit from tPA would not be counterbalanced by the potential for harm to patients presenting with conditions mimicking AIS (a common concern among emergency physicians for precluding tPA use).9,10 Multicenter
apollo medicine 13 (2016) 42–45
[(Fig._3)TD$IG]
45
avoidance of unnecessary thrombolytic therapy in stroke mimics. Like in this case, the patient presents with classical history of acute stroke with normal NCCT head, but age and h/ o OCPs are important features in the presented case. Correct identification of stroke mimics needs clinical expertise and imaging studies. Time-bound clinical as well as imaging assessment is needed to exclude stroke mimic and avoidance of IV thrombolysis in stroke mimics. At the same time, effective thrombolysis in AIS is a good modality to decrease morbidity and mortality. As discussed above, multiple studies indicate safety of thrombolysis in stroke mimics. These findings offer reassurance to stroke physicians not to preclude potential candidates for thrombolytic therapy based on the sole concern that their neurological symptoms may be attributed to stroke mimics.
Conflicts of interest The authors have none to declare.
references
Fig. 3 – MR venogram.
cohort study done by Zinkstok et al.11 concluded that among patients treated with IV thrombolysis, only a few had a final diagnosis other than stroke and complication rate in these stroke mimics was low.
6.
Discussion
The idea of reporting this case is only to highlight the importance of correct identification of stroke mimics and
1. Hemmen TM, Meyer BC, McClean TL, Lyden PD. Identification of nonischemic stroke mimics among 411 code strokes at the University of California, San Diego, Stroke Center. J Stroke Cerebrovasc Dis. 2008;17: 23–25. 2. Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. Distinguishing between stroke and mimic at the bedside: the Brain Attack Study. Stroke. 2006;37:769–775. 3. Ay H, Buonanno FS, Rordorf G, et al. Normal diffusionweighted MRI during stroke-like deficits. Neurology. 1999;52:1784–1792. 4. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. 1995;52:1119–1122. 5. Lyden PD. Extending the time window for thrombolytic therapy: primum non tardare. Lancet Neurol. 2009;8: 1074–1075. 6. Bousser MG, Ross Russell R. Cerebral Venous Thrombosis. vol. 1. London, UK: WB Saunders Co.; 1997: 175. 7. Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin. 1992;10:87–111. 8. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–1711. 9. Mouradian MS, Rodgers J, Kashmere J, et al. Can rtPA be administered to the wrong patient? Two patients with somatoform disorder. Can J Neurol Sci. 2004;31:99–101. 10. Brown DL, Barsan WG, Lisabeth LD, Gallery ME, Morgenstern LB. Survey of emergency physicians about recombinant tissue plasminogen activator for acute ischemic stroke. Ann Emerg Med. 2005;46:56–60. 11. Zinkstok SM, Engelter ST, Gensicke H, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013;44(April (4)):1080–1084.